Mistake or mischief? Did top scientists at Stellenbosch and Cape Town universities make so many honest mistakes in their study? Did they really not know the Health Professions Council of SA (HPCSA) would use it to charge scientist Prof Tim Noakes? Or was there something more contrived behind their research?

British obesity researcher Dr Zoë Harcombe asked those questions in her evidence-in-chief on day six of the HPCSA’s hearing against Noakes in Cape Town today. Harcombe is one of three expert witnesses for Noakes who have flown in from the UK, US and New Zealand.

The public has dubbed them “Tim’s Angels”. There was nothing angelic about Harcombe’s takedown of the study known as the “Naudé Review”. Here’s what Harcombe said about it:

Dr ‎Zoë Harcombe and advocate Ravin ‘Rocky’ Ramdass

The research is a systematic review and meta-analysis of 19 studies. The PLoS (Public Library of Science) One journal published it in 2014.

Lead author is Dr Celeste Naudé of Stellenbosch University’s Centre for Evidence-based Healthcare. Co-authors include Dr Marjanne Senekal. She is associate professor and head of UCT Division of Human Nutrition. Senekal is a consultant to the HPCSA in the case against Noakes.

Another author is Prof Jimmy Volmink, dean of Stellenbosch Faculty of Health Sciences and a member of the Cochrane Collaboration Centre at the Medical Research Council in South Africa.

Dr Marjanne Senekal

Noakes faces a charge unprofessional conduct for giving unconventional advice to a breastfeeding mother on a social network (Twitter). That was a single tweet in February 2014 saying good first foods for infant weaning are low-carb, high-fat (LCHF).

Johannesburg dietitian Claire Julsing Strydom just happened to be on Twitter at the same time and reported him to the HPCSA. Strydom was president of the Association for Dietetics in SA (ADSA) at the time. For background click here to read: The real beef dietitians have with him.

Naudé and her co-authors have concluded that “when people eat a similar amount of energy in the low-carb and balanced diets, there was no difference in weight-loss after three to six months.” In other words, low-carb diets are no better for weight loss than conventional, high-carb, low-fat “balanced diets”.

Harcombe is an expert in systematic review and meta-analysis. She used a formidable forensic scalpel to dissect the Naudé Review and expose all the errors. Many are significant. All but one favour the control, “balanced diet”.

Harcombe said the researchers could just as easily have concluded the opposite: a ‘balanced” (high-carb) diet is no better than a low-carb diet for producing weight loss.

Among the errors, Harcombe said the researchers have:

Included studies that failed their own inclusion criteria.

Used invalid and subjective meta-analysis sub-grouping.

Made data extraction that was “repeatedly inaccurate”. One instance of data extraction was so erroneous, Harcombe called it “absurd”, another inexplicable”.

A major limitation of the review, Harcombe said, is that the authors claim to have reviewed evidence for low-carb diet but have not done so. In other words, they “could not judge low-carbohydrate diets because they did not study them”.

The average dietary intake for 14 studies was 35% carbohydrate, 35% fat and 30% protein. That’s very different from the 5% to 10% carbohydrate and 80% to 85% fat of a genuinely low-carb, high-fat diet.

Harcombe said the review also set isocaloric (having similar caloric values) as a criterion. This negated the satiety advantage of low-carb diets. Satiety is a key effect of the low-carb diet despite a reduced energy intake. Thus, researchers in isoenergetic trials would have had to restrict the caloric intake voluntarily of subjects on the control diet to match this effect.

If the researchers were to redo their research without all the errors, Harcombe said, they would have to make a very different conclusion. They would have to find that the low-carb diet actually works better than the (low-fat, high-carb) control diet for weight loss.

Harcombe and Noakes have done just that in a re-analysis of the Naudé Review detailing all the errors. Their study has gone through the peer-review process and a journal has accepted it for publication.

They have only re-examined one part of the Naudé Review. However, given so many errors in one section, they believe it is unlikely that the rest of the paper is robust.

In her evidence, Harcombe described as “interesting” the media reporting of the review that ensued. Incriminating might be a better adjective.

The authors never mention LCHF, Banting or Noakes. Yet media reports quickly claimed that the review “debunked the Banting diet”. Other reports personalised the message and referred to Noakes as a “celebrity professor”. One said the Naudé Review proved that “Noakes’ low-carb diet is not healthier”.

Dr Vash Mungal-SIngh

One report quoted chief executive of the Heart and Stroke Foundation of South Africa (HSFSA) Dr Vash Mungal-Singh saying: “The current evidence means we cannot recommend a low-carbohydrate diet to the public.”

If Naudé and her co-authors did not proactively relay those messages, it is “interesting” that they did nothing to correct them at the time – or have done since.

Harcombe said these media reports, apart from being incorrect, had “potential for harm”. The many people who are on “Banting”-style diets to treat obesity, diabetes and other conditions and benefitting may have felt worried enough to stop.

She and Noakes uncovered other problems, including that some studies lacked generalisability to whole populations. Two, for example, looked at males only. Overall, Harcombe described the review as “unprofessional” – and worse: “fraud”.

Therefore, I’d say a call for the journal to retract the study cannot be far away.

It is littered with so many errors it raises other disturbing questions. Like how did the authors manage to publish their study at all.

In the background to the study, the authors refer rather archly to “some weight-loss diets widely promoted through the media”. However, the only one they name is the Atkins diet. They say “these diets” recommend a regimen “greatly restricting carbohydrates, with increased protein and unrestricted total and saturated fat intake”. Most of the low-carb diets I’ve ever heard of don’t advise unrestricted total and saturated fat intake. Most put a percentage onto it.

The researchers say nary a word about Noakes or Banting.

Given the controversy and fury swirling around both in medical and dietetic circles at the time, that oversight can seem far more by design than default. The researchers say it is “plausible that these low-carbohydrates could be harmful, especially over the longer term”. They give references, but that’s a statement loaded with bias if ever I read one.

The Naudé Review may also signal a deep rot in the peer-review process. In an article in the Journal of the Royal Society of Medicine in 2006, former BMJ editor Dr Richard Smith, CE of United Health Europe, is damning about the process.

He says there is “little evidence on the effectiveness of peer review, but we have considerable evidence on its defects.

“In addition to being poor at detecting gross defects and almost useless for detecting fraud it is slow, expensive, profligate of academic time, highly subjective, something of a lottery, prone to bias, and easily abused.”

If the Naude Review really does turn out to be more mischief than mistake – as is looking very likely – it will be yet another example of that abuse. It will also be another lesson in unintended consequences that are piling up for the HPCSA in prosecuting Noakes.

Thank you so much Marika for your amazing, detailed coverage of this farce!

I think it is time for the HPCSA and ADSA to be disbanded and replaced with a body of people who actually know what evidence means.

It has become apparent throughout this trial that confirmation bias seems to be the order of the day and those charged with informing the SA public about health and diet are conflicted and really not fit to hold any form of office.

Tim Noakes has conducted himself with poise and dignity in the face of an onslaught that was blatantly preposterous and clearly dragging the name of true science through the mud. That must have been incredibly difficult for him to watch.

Thank you so much again Zoë, Caryn and Nina for your coverage, evidence and clinical dissection of the prosecution case.

Seriously, thank you, Marika, for your daily reporting on this fascinating and historic hearing. I wake up in the morning and read all I have missed while sleeping . . . then see the puzzle pieces artfully assembled here later in the day.

Thank you for giving voice to Prof. Tim Noakes and the health heroines (a.k.a. Tim’s Angels) whom others are striving so hard to silence.

I am in Australia and am following the trial but I’m not sure if I manage to find all the information. Has there been any reaction from the various authors of this study review? Their work is being destroyed, and by all accounts justifiably, but have they said anything in their own defence or are they in hiding out of embarrassment?

The HPCSA called six witnesses, one factual – the dietitian from Association for Dietetics in SA (ADSA), Claire Julsing Strydom who started it all by reporting Prof Noakes to the HPCSA – and five experts – Five gave evidence at November hearing session, one at February 2016. So they’ve all had their say. They don’t seem to me to be embarrassed about anything at all. ADSA has now sent an email newsletter to all members trying to justify their complaint – and the millions this case has cost the HPCSA and Prof Noakes? They are still insisting that it’s “just about Twitter”, which is just nonsense. Strydom’s tweet in reply to Prof Noakes’ tweet made it clear she was furious at the information he gave to the breastfeeding mother. Dietitians don’t want him giving any dietary advice, especially not if it conflicts with theirs. They seem to think they are the only ones who should be allowed to give advice.

Those people who have enough common sense to realise that they need to review their dietary behaviour also have enough common sense to do their own research and then realise the absolute treasure trove of good solid information available on the web and in books like The Real Meal Revolution and others. This has the effect of making dietitians redundant (and miserable). Ask yourself when you last saw a smiling dietitian at the Tim Noakes hearing.

I want to hear the responses of local doctors and cardiologists.
Have they followed the trial?
Have they kept themselves informed?
Have they asked the Noakes Foundation for the relevant science references?
Have they researched the science for themselves?
Have they read up the LCHF science commented on by doctors round the world for alternative views?
And, have they questioned the dietary guidelines?
This is really BIG news, so,
If not then why not?
What are they afraid of?

Prof Noakes, I honour you for the stand that you are taking at such huge personal cost for the sake of the trusting public.
Your dignity, integrity and professionalism remind me of the days when these were the norm for any professional … sadly the evidence is proving that the public’s current lack of confidence in most professionals is fully justified.
Rest assured that the public are deeply indebted to you for what you are doing, and many, many are 100% behind you.
Please continue to be brave and resolute as you have been to date – ultimately the truth always triumphs!
Thank you, Sir, on behalf of all those who will ultimately benefit from your brave, principled stand for the truth and for justice!

I notice Zoe also referred to statins as a “crime against humanity” in her evidence.

I think it’s pretty clear by now that the diet-heart hypothesis is false. However, I came across an even more disturbing thought yesterday. According to Dr. Thomas Cowan, who has just published a new book on the heart, the burning pain in a heart attack is lactic acid damaging the muscle (similar to the burn in the legs when exercising). The problem is that the heart cannot flush, because it doesn’t stop working (unlike the legs when you stop running). Now Cowan says that there was an old medicine ouabain, a plant extract, that used to be used to help this. Interestingly it’s been known since the 1990s that the body actually makes ouabain endogenously (in the adrenal glands). Ouabain is a hormone that is capable of converting lactate to pyruvate – a fuel that the heart can use.

As I expect you know, Marika, all our hormones are made from cholesterol. This includes ouabain. So lowering cholesterol is actually a very unhelpful thing to do.

Zoe Harcombe was superb. The Pro Forma complainant? – not so much. I kept on thinking about the old maxim of holes and the advice to stop digging. Mr Bhoopchand simply managed to emphasize all the negatives of the complaints case during his cross examination whilst most of the audience frequently had to restrain their incredulity AND their mirth. Furthermore, the dissection of the Naude study simply served to confirm the intellectual incoherence coming out of UCT at the moment. Frankly, I would have expected better from Stellenbosch.

Every time I attend one of these sessions I ask myself why the charade has been allowed to continue for so long. It is disgraceful. One would have thought that by now all the people involved with the complainant would have had enough time to bring themselves up to speed with events which are overwhelming the old tired dietary dogma

I really appreciate your coverage of this modern-day medical witch hunt. It is so very striking how desperate these people are. The entire thing is just a farce. It’s been clear from the start that it’s not really about the tweet: there’s some other agenda. The other striking thing is the dignity of Tim Noakes and how he has behaved and handled himself through all this. It’s clear they there’s absolutely nothing they can do to him that would change his dignity or his worth. They can’t touch him. I love hearing the testimony of the angels. Makes me want to stand up and cheer. I wish this was more widely covered in the U.S.

The Naude ‘Review’ is so flawed the authors must be either incompetent or thoroughly biased. Biased and incompetent is the most likely explanation for such poor work, which they clearly hoped would allow them to damage Tim Noakes. The people behind this ‘review’ are unfit to hold a senior position or to advise anyone on their diet. They might want to look upon Zoe Harcombe and see what a real professional looks like. One who puts public health first and doesn’t have a long list of sponsors to keep happy.

So, they call a diet containing 35% carbohydrates ‘low carb’? This has become the classic way to try to discredit a low carb diet. It’s telling that when you want to rig the results against Banting, you increase the carb intake to such a high level. That fact tells you a lot about carb consumption, which is always increased to worsen the result. They never look at proper studies of 5 – 10% carb because the results would sink them without trace. Did they include any of the studies by Volek and Phinney? Not a chance.

Not a chance! The cognitive dissonance in this case has been truly remarkable to behold. Dietitians belong to the Association for Dietetics in SA (ADSA) and various academics and doctors simply ignore evidence that doesn’t suit them. Most unprofessional, I’d say.

Marika, to ignore inconvenient evidence is malpractice of the worst kind. It’s really hard to understand their motives. Surely they can’t all be stupid? But so much is now built on the low-fat fad, including the vested interests of the food and drugs industry. I wonder if admitting this terrible error isn’t just too difficult for many older dietitians and cardiologists, who have invested their whole careers into this folly and prefer to make more people ill than admit they got it wrong. Do the legal implications of this error frighten them? They’re directly responsible for making diabetics ill and I know many are angry. The next generation in the medical world will hold those clinging onto this nonsense with contempt.

This hearing reminds me of the prosecution of John Scopes in Tennessee in 1925 for teaching human evolution. The prosecution looked like blinkered dimwits, whilst Scopes was defended by Clarence Darrow. The ASDA’s leaders would feel right at home in 1920s Tennessee.